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Steubenville Youth Conference

Youth Registration Form

Friday, July 12th through Sunday, July 14, 2019

Open to ALL Current 8th-12th Grade Youth!

NOTE: This form is for YOUTH ONLY. Registration for Adult Group Leaders will open at a different time. Thank you!

Registration is due on Sunday, April 21, 2019.

We’re returning to the much loved Steubenville Youth Conference in Rochester, MN this summer! This awe-inspiring, faith-awakening event is open to all current 8th-12th grade youth. With world renowned chastity speaker Jason Evert speaking this year, and other fantastic speakers like Katie Hartfiel, Paul George and Nic Frank in the mix, it’s sure to be a memorable weekend!  Register by Sunday, January 13th for the early-bird pricing of $325. Cost includes entrance to the conference, meals, 2 nights in a hotel, transportation, and a t-shirt. 

               Steubenville Youth Conference 2019 Tiered Conference Pricing Structure is as follows:

Early Bird Registration: If registering by Sunday, April 21, 2019*

     Cost: $325 ($100 deposit, plus three additional payments of $75)

*Partnership for Youth has offered to return us to the Early Bird Discount for anyone who registers by Sunday, April 21st! The previous Early Bird deadline was listed as Sunday, January 13th.

Regular Registration: If registering between January 14, 2019 – April 28, 2019

     Cost: $340* ($100 deposit, plus three additional payments of $80)

Late Registration: If registering on or after April 29, 2018

     Cost: $355* (Please pay in full.)

*This pricing structure reflects the additional fees applied to the parish by Partnership for Youth, host of the Steubenville Rochester Youth Conference.

               If payment assistance or a separate payment schedule/arrangement is needed, please ask!

Payment will need to be delivered to the Religious Education Office, Attn: Laura Bogue. Please make checks payable to St. Stephen the Martyr Parish. Payments may also be made on-line at www.osvonlinegiving.com/1851/DirectDonate/42983. 

A brief description of the event follows:

Name of Event: Steubenville North Youth Conference

Purpose of Event: To strengthen faith and build community

Location: Mayo Civic Center in Rochester, Minnesota

Date and Time of event: 6:30 AM on Friday, July 12, 2019 until 8:30 PM on Sunday, July 14, 2019

Transportation: Arrow Stage Bus Lines; We will meet in front of the Religious Education Office at
6:15 AM and will attend the 6:30 AM Mass together before departure.

I grant permission for my youth to participate in this youth ministry event that is located away from the parish/school site. This activity will take place under the guidance and direction of Archdiocesan parish/campus youth ministers and/or volunteers from parishes/schools.

As parent and/or guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or heirs, successors, and assigns, to hold harmless and defend St. Stephen the Martyr, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the event arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith and I agree to compensate the parish/school, its officers, directors and agents, an the Archdiocese of Omaha, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.

Parent/Guardian Signature: 

Date: 

April 26, 2019

Photo Release: Pictures of my child taken during the event may be used in print or electronic media for the purposes of publicity for future events, unless I indicate to the Archdiocesan Coordinator of Youth Ministry in writing to the contrary.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Parent or Guardian's Email Address

Email*

Confirm Email*
Minor's E-Mail Address
Steubenville Payment Agreement
A link to the Payment Agreement for the Steubenville Conference 2019 will be sent to you upon submission of this form, and is also available on our Forms and Events page on-line. Please take the time to read over this agreement carefully, and contact us with any questions or concerns.
I understand.
DEPOSIT & PAYMENTS: At the time of registration, please submit your deposit of $100 per participant. This payment is NON-REFUNDABLE and NON-TRANSFERABLE. Please understand that once you have registered, we (the parish) pay a non-refundable, non-transferable deposit to reserve your spot at the Steubenville Conference. *
I understand that a non-refundable, non-transferable deposit of $100 per participant is owed at the time of registration in order to reserve a spot(s) for the Steubenville Conference.
Three additional payments of $75//$80 (depending on amount owed) are requested on February 17th, March 17th, and April 21st of 2019. If payment assistance or a separate payment schedule/arrangement is needed, please ask! PLEASE CHECK ALL THAT APPLY: *
I understand that 3 additional payments will be due following registration, and will make arrangements if a separate payment schedule/arrangement is needed.
I am interested in learning more about financial assistance. Please contact me with more information.
DROPPING OUT OF CONFERENCE: Any participant needing to back out of attending the Steubenville Conference must do so on or before April 28, 2019. A refund of any amount paid (minus the non-refundable $100 deposit) will be issued at that time. With the exception of extenuating circumstances left to the pastor's discretion, anyone dropping out of the conference on or after April 29, 2019 will still be expected to pay the full $325, or $340 if registered after January 13th. Please understand that by this date, we (the parish) have secured hotel rooms and transportation, have paid in full for participants to attend the conference, and are unable to receive a refund. *
I understand that I will only receive a refund for the Steubenville Conference (minus the $100 deposit) if backing out on or before Sunday, April 28th. I agree to pay the full balance for the conference if needing to back-out April 29th or after, understanding that the parish will have already fronted the money to the appropriate vendors/venues by that point.

The Youth Ministry Office would be more than happy to help in any way we can! Please contact us if you have any questions or concerns.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Grade in Current School Year (2018-19)*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size*
Small
Medium
Large
XL
2XL
3XL

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:


Name & Relationship: *

Phone: *

Family Doctor: *

Phone: *

Family Health Plan Carrier: *

Policy #: *

Other Medical Treatment: (In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reverse to myself),

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described).

Choose 'a' or 'b', not both

Specific Medical Information: The parish/school/Archdiocese will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.):


Immunizations: Date of last tetanus/diphtheria immunization:

Does the child have a medically prescribed diet?

Any physical limitations?

Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting?

Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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